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y 30 (2008) 572–577

General Hospital Psychiatr

Treating adult attention deficit hyperactivity disorder inhospitalized psychiatric patients

Ricardo Castaneda, M.D.a,b,⁎, Robert Levy, M.D.a,b, Charles Hazzi, M.D.c,Stephen Ross, M.D.a,b, William Roman, M.D.a, Hamada Hamid, M.D.a

aDepartment of Psychiatry, New York University School of Medicine, New York, NY 10016, USAbBellevue Hospital/New York University Medical Center, New York, NY 10016, USAcDepartment of Internal Medicine, New York University, New York, NY 10016, USA

Received 6 January 2008; accepted 20 August 2008

Abstract

Objectives: We intend to review the importance of appropriately recognizing and managing attention deficit/attention deficit hyperactivitydisorder (ADD/ADHD) in the acute psychiatric hospital setting.Methods:We demonstrate the management of three patients with associated ADD/ADHD diagnosis in the hospital setting. This case series isfollowed by a review of the literature on the treatment of ADD/ADHD with particular focus on inpatient treatment.Results: Given that the core symptoms of ADD/ADHD are inattention, hyperactivity, poor concentration, impulsivity, poor organization andemotional instability, it follows that a comprehensive inpatient treatment plan should address these issues in order to obtain sustained, focusedparticipation on the part of the patient. Suppression of ADD/ADHD symptoms with stimulants greatly enhanced our patients' ability to moreproductively and actively participate in the treatment of the acute psychiatric problems which led to their admission.Conclusions: Currently, no published data exist on prevalence of ADD/ADHD in psychiatric hospitals, rates of treatment and outcome oftreatment with regard to recovery and quality of aftercare. Nonetheless, the benefits of treating ADD/ADHD among psychiatric inpatientsmay be seen in case examples and are also apparent in the data concerning treatment of ADD/ADHD in the dually diagnosed.© 2008 Elsevier Inc. All rights reserved.

Keywords: ADD/ADHD; Hospitalized psychiatric patients

1. Introduction

Attention deficit disorders/attention deficit hyperactivitydisorders (ADD/ADHD) are more frequently diagnosed andtreated in psychiatric outpatients than inpatients [1–3].Among outpatients, prevalence rates for ADD/ADHD areestimated at 3–7% for children [4] and 4.7% for adults [5].While many adults suffer significant impairment from ADD/ADHD, screening for this disorder, in contrast to pediatricpopulations, is rarely routinely done. The lack of clinicalrecognition may contribute to lower rates of adult ADD/ADHD treatment compared to children, despite comparableprevalence rates.

⁎ Corresponding author. Bellevue Hospital/New York UniversityMedical Center, 550 First Avenue, New York, NY 10016, USA. Tel.: +1212 562 3455; fax: +1 212 562 8085.

E-mail address: ricardo.castaneda@nyumc.org (R. Castaneda).

0163-8343/$ – see front matter © 2008 Elsevier Inc. All rights reserved.doi:10.1016/j.genhosppsych.2008.08.006

Similarly, on psychiatric inpatient units, children andadolescents are more likely to receive treatment for ADD/ADHD than are hospitalized adults. Far less is known about thetreatment of ADD in adult inpatients. While the prevalence ofADD/ADHD in hospitalized adults is not established, it issuspected that the treatment of adult ADD/ADHD inhospitalized psychiatric patients is relatively uncommon.

The hesitation to treat adult ADD/ADHD on inpatientunits may arise from both underdiagnosis and uncertaintyregarding the use of stimulants in combination with otherpsychotropic medications. Skepticism regarding clinicaloutcomes when treating ADD/ADHID in the setting ofsevere comorbid affective, psychotic, personality and sub-stance dependence disorders may also contribute to sub-optimal management.

This paper argues, through the use of case examples, thatadult ADD/ADHD in the acute psychiatric setting consti-tutes an active psychiatric problem warranting diagnosis

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and treatment. While ADD/ADHD affects at least 5% ofadults [5], a literature search, using PubMed, Medline,IndexMedicus and PsycInfo, failed to yield a single articleaddressing the treatment of ADD/ADHD in psychiatricallyhospitalized adults.

The negative effects of ADD/ADHD include lower socialfunctioning, poorer educational and employment outcomes,and increased rates of criminal activities, motor vehicleaccidents, injuries, unprotected sex, substance use andpsychiatric comorbidities [6–9]. There may be an evenmore severe toll for individuals who require psychiatrichospitalization. The consequences of neglecting ADD/ADHD on psychiatric inpatient units may include a negativeimpact on both the course of inpatient care and outcomesafter discharge. Our clinical experience suggests that ADHD/ADD hinders patients' ability to communicate, listen, learn,participate and otherwise benefit from educational interven-tions and interferes with their incorporation into thetreatment milieu. On discharge, ADD/ADHD renderscompliance less likely and relapse more probable.

2. Case examples

2.1. Bipolar disorder and polysubstance dependence

Mr. M is a 27-year-old Hispanic male with a long historyof bipolar I disorder, polysubstance dependence (cocaine,alcohol, marijuana) and anti-social personality disorder whowas admitted to an inpatient dual-diagnosis unit at a NewYork City public hospital. The patient had a history ofmultiple psychiatric admissions and past suicide attemptsand incarcerations. He presented in a mixed manic state,exhibiting euphoria, irritability, pressured speech, decreasedneed for sleep, flight of ideas, impulsivity, distractibility,psychomotor agitation and grandiosity. Psychotic symptomsincluded paranoid and grandiose delusions, thought disorderand command auditory hallucinations to kill himself. Arelapse of crack cocaine, alcohol and marijuana exacerbatedhis symptoms. He was admitted to the unit involuntarily.

Initially, the patient was treated with olanzapine 30 mg poQHS, valproic acid 1000 mg po bid and clonazepam 1 mgtid. The patient's acute agitation subsided over the first fourhospital days and he was tapered off the clonazepam. Overthe next week, psychotic symptoms remitted; he was nolonger delusional and had no auditory hallucinations. Hismanic symptoms, including decreased need for sleep, flightof ideas, grandiosity and agitation also improved markedly,but he continued to be hyperactive, intrusive, loud anddistractible. These symptoms persisted despite a valproicacid level of 120. Lithium carbonate was added and titratedup to 900 mg bid over the course of a week. With a lithiumlevel of 1.1, he became less intrusive and loud, but thehyperactivity and distractibility persisted.

On admission, there was a question of whether the patienthad comorbid ADD/ADHD given a history of hyperactivityand distractibility dating back to childhood. However, with a

long history of bipolar disorder and chronic drug depen-dence, it was initially difficult to substantiate this diagnosis.With the help of collateral history from the family andneuropsychological testing, the patient was diagnosed withattention deficit disorder, combined type.

The patient was started on atomoxetine (Strattera). At 40mg qam, he showed no response; the dose was titrated up to100 mg qam over the next 2 weeks and the patient showed amarked reduction in hyperactivity, impulsivity and distract-ibility. He was able to sit through multiple groups each dayand synthesize the information learned. This dramaticchange allowed the patient to be discharged within thenext week to an outpatient dual-diagnosis day program.

2.2. Major depression and alcohol dependence

A 34-year-old married white female was admitted fordepression and suicidal ideation of several weeks' duration.She had a history of multiple episodes of major depressionand alcohol dependence, which was in remission for over 4years. On admission, she complained of depressed mood,anxiety, low energy, difficulty sleeping, guilt and loss ofappetite with attendant weight loss. She also reported poorconcentration and attention, as well as worsening difficultywith task completion, which undermined her ability to carefor her 4-year-old son. The patient reported that this was verydamaging to her self-esteem. She had begun takingparoxetine 20 mgs QD and clonazepan 1 mg HS 2 weeksprior to admission, without symptom relief. She wasadmitted with a diagnosis of major depression and alcoholdependence in full remission.

The patient had responded well to treatment withparoxetine during three previous episodes of major depres-sion, so this medication was continued during the currenthospitalization. Clozazepan 1 mg QHS was also continuedand trazodone 50 mg QHS was initiated for sleep.

Within 1 week of hospitalization, she experienced a rapidresolution of her depressed mood and was no longer suicidal.Poor attention and concentration and difficulty sleepingpersisted; the patient and her husband stated these symptomsdated back to her childhood.

Neuropsychological testing strongly suggested attentiondeficit hyperactivity disorder, and the patient was started onConcerta 36 mg bid. Full remission of her inattention andproblems with concentration was attained upon upwardtitration of Concerta to 72 mg bid. Her sleep normalized andshe requested discontinuation of trazodone and Klonopin 2.5weeks into the hospitalization. She was discharged onparoxetine 20 mg daily and Concerta 72 mg bid. Paroxetinewas discontinued 18 months after hospitalization. Threeyears later she remains on Concerta 72 mg bid.

2.3. Psychotic mania

Mrs. M., a 69-year-old white female was admitted fortreatment of manic behavior that included threatening herschizophrenic son with a hammer and knife. On initialevaluation, Mrs. M. presented with significant thought

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disorganization, pressured speech and tangential thoughtprocess. She reported a history of Ritalin-responsive attentiondeficit disorder as well as bipolar disorder. She was placed onvalproic acid and risperidone; after 1 week of hospitalizationthe patient showed no response. Medication noncompliancewas suspected and she was switched to oral solutions of bothmedications. Valproic acid was titrated to 750 mg po bid andrisperidone to 3 mg qHS. Her serum valproic acid level was76.5. She began to manifest mild extrapyramidal symptomsand benztropine 3.5 mg was added.

Despite compliance with the medication regimen, shecontinued to exhibit pressured speech and a tangentialthought process. She also complained of inability to sleepdespite lorazepam 1 mg and trazodone 50 mg HS. Thepatient was also noted to manifest many symptoms, withchildhood onset, suggestive of ADHD, including impairedconcentration, distractability, difficulty following instruc-tions, poor organization and hyperactivity, as well asfidgeting of her hands and excessive speech. She haddifficulty waiting for her turn at mealtime and also wouldinterrupt and intrude upon others.

While many of these symptoms may reflect residualmania, the prior diagnosis of attention deficit hyperactivitydisorder suggested that a trial of Ritalin-SR 40 mg tid may beappropriate. The patient enthusiastically agreed to this, butrefused to continue on Depakote or accept a trial of anothermood stabilizer such as lithium. Nevertheless, she showed adramatic improvement in thought process and mood and acessation of pressured speech. Her hyperactivity decreasedand she showed improvement in her ability to sustainattention and participate in tasks requiring concentration. Shereported relief of her sleep difficulties and requesteddiscontinuation of bedtime hypnotics and trazodone.

The treatment team felt that Mrs. M. would benefit from amood stabilizer and continued hospitalization. The patient,however, sought discharge through the courts and wasreleased by a judge's order. She agreed to take only Ritalin-SR upon discharge.

2.4. Using stimulants in general adult psychiatric patients

The failure to recognize and treat hospitalized adults withADD/ADHD stands in stark contrast to the increased use ofstimulant and nonstimulant medications in outpatient settings[9–11]. With a few caveats, it is widely documented thattreatment of ADD/ADHDwith stimulants is effective, safe [12–17] and rarely associatedwith long-term adverse effects [18–19].

The mainstay of pharmacologic treatment of ADD/ADHD is stimulants. Stimulants that effectively treatADD/ADHD include amphetamines (dextroamphetamineand mixed amphetamine salts such as Adderall), methyl-phenidate (Ritalin, Concerta and others) and pemoline (untilrecently marketed under the name Cylert) [12–17]. Amphe-tamines and methylphenidate enhance dopaminergic activitythrough re-uptake inhibition and enhancement of release.Amphetamines are noncatecholamine, sympathomimeticamines with peripheral effects which include increasing

blood pressure, weak bronchodilation and respiratorystimulation. Dextroamphetamine sulfate is the dextro isomerof D,L-amphetamine sulfate that is available in a short-acting(DextroStat) and sustained release form (Dexedrine).DextroStat is dispensed in 5- and 10-mg tablets. With two5-mg tablets, peak blood levels are reached on average 2 hpost-administration with an average half-life of 10.25 h.Dexedrine spansule capsules are designed to release theactive ingredients more gradually and are available in 5-, 10-and 15-mg dosages. Maximal concentrations of the 15-mgsustained release capsules are reached 8 h post-administra-tion with a half-life of 12 h. Methamphetamine hydro-chloride (Desoxyn) has an onset of action of 20-30 min and ahalf-life of 4-5 h. It is predominantly metabolized in the liverand excreted in the urine. Adderall (immediate release andextended release) contains D-amphetamine and L-ampheta-mine at a 3:1 ratio. Immediate release reaches peak plasmaconcentration at 3 h and extended release at 7 h post-administration, and the average elimination half-lives are 10and 13 h for D-amphetamine and L-amphetamine, respec-tively. Administration of Adderall with food prolongs thetime of maximum plasma level by approximately 2.5 h.

The methylphenidates (Ritalin, Ritalin-LA) and dex-methylphenidate (Focalin, Concerta) are identical in chemi-cal formula, differing only in racemic structure andmechanism of delivery. Methylphenidate's mechanism ofaction is not well understood but is thought to be a centralnervous system stimulant that blocks norepinephrine anddopamine reuptake in the presynaptic neuron. Ritalin's timeto maximum plasma concentration, in normal adults, is onaverage 1.9 h for regular tablets, 4.7 h for SR (slow-releaseform) and 2.0 h for LA (long acting). The half-lives forRitalin, Ritalin-SR and Ritalin-LA are 3.5 (±1.9), 8 and 3.3(±0.4) h, respectively.

The common side effects associated with stimulants, suchas nervousness and insomnia, are infrequent among adultswith ADD/ADHD. Increased attention to the potential risksof stimulants resulted from the recommendations released bythe FDA Drug Safety and Risk Management AdvisoryCommittee. Post-marketing safety data from 1999 to 2003reviewed by the committee revealed that there were fiverelated sudden deaths and 17 nonfatal cardiovascular andcerebrovascular accidents in adults related to amphetamine/methamphetamine. One sudden death and 11 nonfatalcardiovascular and cerebrovascular accidents in adultsrelated to methylphenidate occurred. Methamphetamineand dexmethylphenidate had no reports meeting the criteriafor the World Health Organization's sudden death criteria ornonfatal cardiovascular and cerebrovascular accidents inadults. Patients across the reports varied in age and riskfactors; however, the committee concluded that the potentialrelationship between hypertension, stimulants and cardio-vascular/cerebrovascular disease warrants cautious use ofstimulants in patients with the aforementioned risks. Whilethese complications are exceedingly rare, more common sideeffects include insomnia, headache, edginess and mild

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increases in heart rate and blood pressure [14–16].Intravenous methylphenidate has also been associated withoccasional toxic hepatitis [20–22]. In addition, severevasoconstriction caused by sympathomimetic drug overdosemay lead to acute ischemic hepatitis and multi-organ failure.Finally, there is a small risk of stimulant-induced mania orpsychosis, which has been reviewed elsewhere [23].

Atomoxetine, a nonstimulant norepinephrine reuptakeinhibitor, has been shown to be moderately effective with arelatively benign side-effect profile [24]. The most commonside effects include gastrointestinal upset, mild increase inheart rate and blood pressure, and sexual side effects.However, long-term atomoxetine use is also associated withincreased heart rate and blood pressure. While there are noguidelines or recommendations published to date regardingincreased risk of cardiac and cerebrovascular disease, theserisks should be considered when prescribing this medication.

With the probable exception to desipramine and bupro-pion (Wellbutrin), antidepressants, generally, are ineffectiveas monotherapy for ADD/ADHD, but may play an adjunctiverole when used in combination with stimulants [25–27].These agents often provide greater benefit for the behavioralmanifestations than for cognitive symptoms of ADD.

2.5. Using stimulants in adult psychiatric with comorbidsubstance abuse

We suggest it is imperative to address comorbid addictionand ADD/ADHD among hospitalized psychiatric patients.While highly contested [28–30], several reports andemerging clinical practice demonstrate the efficacy andsafety of combining ADD/ADHD pharmacotherapy withaddiction treatment [2,3]. Indeed, the treatment of ADD/ADHD seems to exert a protective rather than an exacerbat-ing effect on treatment outcomes. Effective treatment ofADD/ADHD symptoms enhances the patients' ability toimplement aftercare addiction strategies, and it eliminates amajor precipitating factor for relapse, mainly the tendency ofsome individuals with ADD/ADHD to attempt to self-medicate their ADD/ADHD symptoms with cocaine [17]. Ina meta-analysis of studies that compare treated and untreatedADHD in substance-abusing adolescents, the treated ado-lescents had half the risk of substance abuse of the untreatedadolescents [27]. Methylphenidate and dextroamphetaminehave been safely administered to cocaine-dependent adultswithout evidence of severe side effects or increased drugcraving [3,31]. However, in one small, randomized con-trolled, cross-over trial of 25 adults with ADHD andcomorbid substance dependence, there was no difference inefficacy found in subjects receiving low-dose methylpheni-date [30]. In this study, subjects were titrated up to amaximum of 45 mg methylphenidate daily. Further rando-mized trials with optimized doses of stimulants arenecessary. Farone et al. [31] demonstrated that patientswith ADHD and comorbid substance dependence did notincrease the rate of abuse with substances when prescribedstimulants. Our research and clinical experience should

assuage concerns expressed by early investigators that short-acting stimulants may be less safe than longer-actingpreparations in the dually diagnosed [32].

2.6. Using stimulants with other psychotrophic medications

One of the main concerns of ADD/ADHD treatment inpsychiatric patients is drug interactions. In all but a fewcases, which will be described below, stimulants can besafely coadministered with drugs used in psychiatricinpatient settings. There have been no adverse interactionsreported between stimulants and antipsychotics; in fact,coadministration may lessen the likelihood of stimulant-induced exacerbation of psychosis due to the striataldopaminergic blockade afforded by the antipsychotics.

With regard to mood stabilizers, stimulants are safe whenused in combination with lithium, valproic acid andlamotrigine. Toperimate (Topamax) and zonisamide (Zone-gran) may alkalinize the urine by inhibiting carbonicanhydrase, thereby decreasing the elimination of themetabolites of amphetamine salts. Thus, a downwardadjustment of amphetamine dosage may be indicated whencombined with these anticonvulsants.

Drug interactions between stimulants and other sym-pathomimetic medications such as appetite suppressants,ephredine-containing compounds and some asthma inhalersare an important concern. The clinician should nevercoadminister MAO inhibitors with stimulants and shouldbe mindful of the potential interactions between stimulantsand tricyclic antidepressants. Finally, methylphenidate mayinhibit the metabolism of coumarin anticoagulants, pheno-barbital, phenytoin and tricyclics, necessitating a downwardadjustment of these medications.

The noradrenergic agonist atomoxetine has not beenshown to interact adversely with any of the antipsychotic ormood-stabilizing medications. Its level may rise markedlywhen given with cytochrome P450 206 inhibitors such asfluoxetine, which should be avoided. It too should not beadministered with the MAO inhibitors.

2.7. Stimulant use in patients with comorbid medicalproblems

Since ADD/ADHD is a chronic disorder with onset inchildhood, the clinician should have a particularly high indexof suspicion for medical illness in adults presenting with anacute onset of symptoms. An estimated 20–40% ofhospitalized psychiatric patients have comorbid medicalillness [33]. Prior to making psychiatric diagnosis, acomplete review of systems, physical exam and laboratorywork (blood and urine) is appropriate; if clinically warranted,a noncontrast CT of the brain should be obtained as well.Vigorous assessment is crucial due to the potential ofmedical problems mimicking or exacerbating psychiatricillnesses. The array of medical issues that could complicateand confuse a diagnosis of ADD/ADHD is extensive. Theclinician must consider neurological and metabolic dis-orders, neoplasms, environmental toxins, nutritional

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deficiencies, infectious disease and autoimmune disorders.In addition, medication side effects and alcohol or drugintoxication or withdrawal may present in ways similar toADD/ADHD. Milin et al. [33] have delineated some of thediagnostic difficulties inherent to this situation. They stressthe need to obtain accurate histories of symptoms from timeperiods prior to the onset of substance abuse and advise theclinicians to interview patients after they have attained someperiod of abstinence from alcohol and drugs [33].

The most frequent non-CNS side effects of all stimulantsare cardiovascular, relating to their sympathominetic proper-ties. Amphetamines and methylphenidate may induce orexacerbate cardiac arrhythmias, hypertension and chest pain,and should be used judiciously or not at all in such situations.Amphetamines may also aggravate glaucoma and thyrotox-icosis symptoms. Methylphenidate and pemoline have lesssympathetic activity, which may make them somewhat moresuitable in the above-noted situations, but they do have higherrates of hepatotoxicity. Atomoxetine selectively inhibitsnorepinephrine re-uptake and can have similar side effects.

In medically ill patients who can tolerate stimulants,identifying and treating ADD/ADHD lead to enhancedcompliance with medical treatment [34]. This is particularlyimportant when managing a disease such as diabetes, wherecurrent recommendations for tight control require scrupulousattention to blood glucose monitoring, insulin dosing anddiet. Compliance is also essential in the management of HIVand chronic viral hepatitis. Effective long-term treatment ofthese viral illnesses requires adherence to an often difficultand complicated multidrug regimen, and conscientiousfollow-up with frequent testing and doctor's visits.

3. Conclusion

Several factors help explain why adult ADD/ADHD oftengoes untreated in psychiatric inpatients. First, inpatient staffare most attuned to the most prevalent diagnoses in thepopulation they treat: schizophrenia-spectrum, mood, anxi-ety, personality and substance abuse disorders. Second, mostpsychiatrists are not adequately trained to diagnose and treatadult ADD/ADHD. As a result, they may miss the diagnosis,especially because there is a significant overlap between thesymptoms of ADD/ADHD and symptoms of the disordersthey are most accustomed to treating. In addition, theseclinicians may be unfamiliar with the use of stimulants ormay feel that they are universally contraindicated incomorbid psychiatric and medical patients. Psychiatristsand other staff may also have excessive fears regarding theinteraction of stimulants with other medications or theircapacity to precipitate substance abuse.

Given that the core symptoms ADD/ADHD are inatten-tion, hyperactivity, poor concentration, impulsivity, poororganization and emotional instability, it follows that acomprehensive inpatient treatment plan should address theseissues in order to obtain sustained, focused participation on

the part of the patient. In fact, it has been our experience in alarge city hospital that suppression of ADD/ADHD symp-toms with stimulants can greatly enhance patients' ability tomore productively and actively participate in the treatment ofthe acute psychiatric problems which led to their admission.

Among the advantages derived from the suppression ofADD/ADHD symptoms in psychiatric inpatients areimprovement in concentration and ability to focus, whichfacilitate their participation in therapeutic activities. Further-more, it is commonly recognized that patients with ADD/ADHD sleep better once stimulants are initiated, diminishingthe need for agents used to address insomnia. Effectivetreatment of ADD/ADHD also permits patients to bettermodulate their mood. Unrecognized and untreated, ADD/ADHD symptoms may be falsely attributed to residualsymptoms of co-occurring psychiatric or medical ailments, tosuboptimal medication response or medication side effects.

Beyond anecdotal accounts, little is known regardingthe consequences of treating or failing to treat ADD/ADHD in hospitalized psychiatric patients. Quantifyingand defining the clinical, social and financial ramificationsof ADD/ADHD among psychiatric inpatients awaitrigorous study. Currently, no data exist on the prevalenceof ADD/ADHD in psychiatric hospitals, rates of treatmentand outcome of treatment with regard to recovery andquality of aftercare. Yet, as we have described, the benefitsof treating ADD/ADHD may be seen in case examplesand are also apparent in the data concerning treatment ofADD/ADHD in the dually diagnosed. Further clinicalresearch in this area will help identify the relationshipbetween ADD/ADHD and acute psychiatric disorders, theimpact of ADD/ADHD in hospitalized patients and theoptimal approaches to its management.

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